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Catheter Ablation

Increasing Your Quality of Life: Catheter Ablation versus A-Fib Drugs

When seeking your Atrial Fibrillation cure, you’re often faced with the choices of catheter ablation versus antiarrhythmic drugs therapy.

We know from previous research studies that it’s safer to have an ablation versus living a life on antiarrhythmic drug therapy (AAD). (See Ablation Safer Than Life on Antiarrhythmic Drugs.)

But how do the two treatments compare when it comes to improvement in general health and ‘quality of life’?

Measuring ‘Quality of Life’

To determine success after treatment, researchers traditionally measure if A-Fib recurs using periodic ECGs. But this is “hardly a measure of successful treatment”, says Dr. Carina Blomstrom-Lundqvist, principal CAPTAF investigator from Uppsala University in Sweden.

CAPTAF stands for ‘Catheter Ablation compared with Pharmacological Therapy for Atrial Fibrillation‘.

The CAPTAF clinical trial is one of the first studies in which improvement in ‘quality of life’ was the goal. The trial compared the Atrial Fibrillation treatment effects of ablation versus antiarrhythmic drugs.

One-year results were presented in August at the 2017 European Society of Cardiology (ESC) Congress.

The CAPTAF Clinical Study

The CAPTAF trial enrolled 155 symptomatic patients with paroxysmal or persistent A-Fib at four Swedish centers and at one center in Finland.

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

A-Fib Drug Therapies

All enrolled patients had to have failed one drug therapy (rate or rhythm control). The average age of the enrolled patients was 56 years. Nearly three-quarters had paroxysmal A-Fib. On average they had been diagnosed with A-Fib for about 5 years, and 70%-80% of the patients had severe or disabling symptoms.

Catheter ablation (RF)

Patients received a subcutaneously implantable cardiac monitor 2-m onths prior to the start of the study (to establish a baseline ‘burden’ of A-Fib, i.e. the proportion of time in A-Fib). Then participants were randomized to ablation with pulmonary vein isolation or antiarrhythmic drug therapy. (The study protocol required patients randomized to the ablation regimen to be completely off antiarrhythmic drugs by 6 months after their ablation procedure.)

The primary goal of the study was a change in general health-related quality of life.

CAPTAF Results: Overall Health & ‘Quality of Life’ Improved More after Ablation

Overall Health: After 12 months of follow-up, the ablation group showed a greater improvement in average overall health by 11.0 points versus 3.1 points improvement in the drug group (as measured by a standard survey instrument). The 8-point difference in gain between the two groups was statistically significant.

Quality of Life: The quality-of-life domains (general health, physical function, mental health, role-emotional, role-physical, and vitality) improved significantly more in the ablation group than in the drug group. No significant differences were shown in the remaining two domains (bodily pain and social functioning).

AF Burden: The AF burden of the ablation group was decreased by an average of 20% points versus 12% points among the group on antiarrhythmic drugs. The change from baseline did not reach statistical significance between treatment groups.

The complication rates were comparable between treatment groups.

Summarizing the Results

About the difference in quality of life, Dr. Carina Bloomstrom-Lindqvist, principal CAPTAF investigator, explained that continued treatment with an antiarrhythmic drug in the drug group of patients compared with no drug treatment in the ablated patients “is absolutely the explanation” for the observed difference in quality of life.

Regarding her findings, she said, “Using quality of life as the primary endpoint of a trial for the first time, we demonstrated that pulmonary vein isolation [PVI] is significantly more effective than antiarrhythmic drugs…even at an early stage of their disease.”

Want a Better Quality of Life? Get a Catheter Ablation

“Using quality of life as the primary endpoint…PVI is significantly more effective than antiarrhythmic drugs…”

The CAPTAF clinical study, though small, goes much further than previous studies and is a significant milestone for Atrial Fibrillation patients. This was one of the first studies to focus on quality of life after treatment.

The CAPTAF results prove scientifically that ablation works better for A-Fib patients than antiarrhythmic drugs (AADs).

If you have A-Fib and want to improve your quality of life―get a catheter ablation. It makes you feel better than a life on antiarrhythmic drugs.

Remember: Seek your Cure!
Anyone no longer in A-Fib can tell you how wonderful it is
to have a heart that beats normally again.

Resources for this Article


CASTLE AF Study: Live Longer―Have a Catheter Ablation!

Catheter ablation actually reduces death rates and hospital admissions. That’s the finding in the CASTLE AF trial, a key heart disease study, by Dr. Nassir Marrouche and his colleagues.

In a presentation at the 2017 European Cardiology Congress in Barcelona, Spain, Dr. Marrouche described CASTLE-AF study participants as having A-Fib, advanced heart failure (i.e., low ejection fraction) and an Implantable Cardioverter Defibrillator (ICD).

The multicenter CASTLE-AF trial focused on patients with A-Fib and systolic heart failure.

The CASTLE-AF trial enrolled 398 patients in 33 sites across Europe, Australia and the US between 2008 and 2016. Patients were randomized to receive either radiofrequency catheter ablation or conventional drug treatment.

The study set out to definitively test the ability of A-Fib ablation to improve hard outcomes in patients with symptomatic paroxysmal or persistent A-Fib and a left ventricular ejection fraction (LVEF) of ≤35 percent (dangerously low percent). Median follow-up period was 37.8 months.

Results: Ablation Improves Quantity Not Just the Quality of Life

After catheter ablation, the death rate of trial patients was lowered by an amazing 47%! This is a lot better result than research studies using ICDs with drug therapy to lower the death rate in similar patients.

Before this study, catheter ablation was known to improve quality of life, but unexpected it also improved life outcomes (the quantity of life, how long one lives).

In addition, there may be a “major impact” on reducing costs associated with hospitalizations.

Ablation Improves Ejection Fraction

Once we study the soon-to-be published CASTLE-AF results, we can document what we’ve often observed anecdotally, that catheter ablation improves lower-than-normal ejection fraction and consequently cures a major component of heart failure.

Dr. Marrouche recommends EPs treating heart failure patients with A-Fib to “ablate them early on, very soon in the disease stage.”

My Anecdotal Evidence: Just last month I advised a 73-year-old man in persistent A-Fib to have an ablation by Dr. Andrea Natale. After only one month in sinus, his ejection fraction improved from a low 35% to a normal 55% (normal range is 50 to 75 percent)!

The CASTLE-AF study could pave the way for wider adoption of catheter ablation for treatment of A-Fib.

Even though he’s only a month into his blanking period, he feels terrific.

Wider Adoption of Catheter Ablation?

The CASTLE-AF study results could be a game changer for Atrial Fibrillation patients! Results could pave the way for wider adoption of catheter ablation and may prompt changes in current guidelines for treatment.

CASTLE-AF stands for Catheter Ablation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and Atrial Fibrillation

Resources for this Article

In Layman’s Terms: What is Post-Ablation ‘Recurrence’?

“Recurrence” or “Re-connection” is a general term electrophysiologists (EPs) use to describe when A-Fib returns after a successful catheter ablation.

Heart tissue is very tough and resilient. There is a tendency for ablated heart tissue to heal itself, regrow the ablated area, reconnect, and start producing A-Fib signals again.

Illustration: cyroballoon ablation

But if this happens, it usually occurs within approximately the first three to six months of the initial catheter ablation.

This type of recurrence may happen because the heart tissue was not originally ablated properly, the burn lesion may not have been deep enough (transmural).

In practice, there are four basic types of recurrence found primarily when using RF point-by-point ablation…continue reading more about recurrence…

A Primer: What is the Typical Progression of an Ablation for A-Fib?

In his AF Symposium presentation, Dr. Pierre Jais, of the French Bordeaux group made a reference to the ‘typical progression of a catheter ablation procedure.‘ Readers may ask, what does he mean? What is the typical progression of an ablation procedure?

The Goals of Catheter Ablation for A-Fib: Let’s start by looking at the two main goals of a catheter ablation for A-Fib:

Restore the heart to normal sinus rhythm
Eliminate the symptoms of A-Fib

Additional benefits: Achieving these goals also relieves the patient from the associated risks such as blood clot formation, stroke and increased risks of dementia and mortality.

The EP Lab: Typical Ablation for Persistent A-Fib

We know that Atrial Fibrillation is not a ‘one-size fits all’ type of disease. Every operating electrophysiologist (EP) caters each catheter ablation to the specific patient’s needs. In this simplified example we are looking at the progression of a typical ablation for Persistent A-Fib:

Dr Ali Sovari in EP lab, Oxnard, CA at

Dr Ali Sovari in EP lab, Oxnard, CA

1. Mapping: First, the sources of the rogue A-Fib electrical signals are mapped using a computerized system.

2. Ablation/Isolation: The tip of the catheter is then maneuvered to the various sources of the A-Fib signals (usually starting with the openings to the pulmonary veins). Using RF energy (or Cryo) a tiny burn or lesion is made at each location to disrupt (or ablate) the electrical pathway.

3. Rogue signals terminate or transition: As the series of lesions progress, more and more of the A-Fib signals stop. Or, A-Fib signals may transition into Atrial Flutter which is a more stable and less erratic heart rhythm.

4. Re-Mapping/ablation: At this point it is not uncommon for some A-Fib signals to continue. So, one or more rounds of mapping and ablation may be required to stop any remaining sources of arrhythmic signals.

 5. NSR or Tachycardia: Finally, the heart typically transitions to either normal sinus rhythm (NSR) or a stable atrial tachycardia (a regular but fast heartbeat).

Outcomes After the Ablation

NSR: After their ablation, many patients will be in normal sinus rhythm (NSR). Hurray! Obviously, this is the best outcome.

Stable Atrial Tachycardia: A second good outcome is being in stable atrial tachycardia, i.e., a regular but fast heartbeat. It’s not NSR, but being in atrial tachycardia instead means the patient is NO LONGER in A-Fib.

Graphic: Cryoablation heat withdrawl at

Graphic: Cryoablation heat withdrawl

Why is stable atrial tachycardia still a good outcome? Typically, your heart will heal itself over the following months—called the ‘blanking period’ and, on its own, return to normal sinus rhythm (NSR). (That’s why you should wait for the 3+ months blanking period before you decide if your ablation is a success.)

Benefits from Failed Ablation? When the patient doesn’t return to NSR (or tachycardia), researchers who studied the follow-up data, found a few ‘side’ benefits to a ‘failed’ ablation. Some patients found their A-Fib symptoms were less intense or shorter in duration. Some patients found they could take certain medications that prior to their ablation had been ineffective.

Conclusion: So, either way, a catheter ablation offers benefits. You may still reap some substantial benefits from the previous “failed” ablation even if you need a second (or third) ablation.

Atrial Fibrillation PVI: Can the Need for Multiple Ablations be Forecasted?

Could the necessity for multiple ablation procedures be predicted? According to a research study, the answer is YES!

In a study of patients who had catheter ablation of the Pulmonary Veins (PVs) for paroxysmal (occasional) A-Fib, 8% had to have more than two ablations to be A-Fib free.

The only independent predictor of the need for multiple procedures was the presence of non-PV triggers. According to this research, electrophysiologists (EPs) should check for non-PV triggers such as at the ligament of Marshall.

Illustration of RF ablation at

Illustration of RF ablation

The lesson to be learned from this study: When having an ablation, make sure your Electrophysiologist (EP) is experienced at tracking down (mapping) and ablating (isolating) non-PV triggers.

For example, I reviewed the an O.R. (Operating Room) report of a patient who, after isolating the PVs, was still in A-Fib. Instead of looking for non-PV triggers, the EP just electrocardioverted the patient back into sinus rhythm. This does sometimes work. But not in this case. The ablation failed.

This is particularly important for EPs doing CryoBalloon ablations.

Graphic: Cryoablation heat withdrawl at

Illustration: Cryoablation heat withdrawl

Find EPs Experienced at Ablating Non-PV Triggers

When getting a CryoBalloon ablation, you need to find an EP who is willing to do more than just isolate your PVs—someone who will put out the extra effort to find and ablate non-PV triggers such as at the ligament of Marshall.

To do this, your EP may have to replace the CryoBalloon catheter with an RF catheter to ablate these non-PV triggers. This may require mapping and ablation skills not all EPs have.

What to Ask Prospective EPs

To find the right EP for your CryoBalloon ablation ask:

What do you do if I’m still in A-Fib after you do the CryoBalloon ablation?

(You want to hear they’ll search for and ablate non-PV triggers.)

For more about Ablating Non-PV Triggers, see my article: CryoBalloon Ablation Study: 30% of Patients Required RF to Achieve Isolation

Note: This research study was conducted before the widespread use of Contact Force sensing catheters, whose use is another contributor to the reduction of recurrence and need for multiple ablation procedures.

References for this article

At Age 13, Treatment for Acne Reveals Need for a Cardiologist! A-Fib Hits Early

Warren D.

By Warren Darakanada, Los Angeles, CA, August 2017

“As I write about my A-Fib, I am 23 and just starting my adult life as a financial and economic consultant. But my cardiac story actually starts about ten years ago.

At age 13, I got a severe acne breakout that brought me to the doctor’s office. While waiting to see the doctor, a nurse decided to take my vitals and blood pressure. While the diastolic pressure was normal, the systolic was above 140 mmHg. Without a doubt, I needed to see a cardiologist.

Further investigation revealed that I also had an elevated cholesterol level. Luckily, my blood glucose level was normal. I went through a series of tests to rule out causes of secondary hypertension. Luckily or unluckily, nothing was found.

Since I was a low-risk patient who could benefit from lifestyle modification, and given my age, I was not prescribed any medication or procedure.

At Age 18, A Shock to be Diagnosed with A-Fib!

Over the next years, I had several EKGs, but it was not until a routine cardiologist visit when I was 18 that I was diagnosed with atrial fibrillation. I think I had A-Fib for some time prior to my diagnosis, but had no idea my heart beat was irregular.

I was 18, and in shock! I didn’t know what to do. I didn’t know what to think or feel.

I was in shock! I didn’t know what to do. I didn’t know what to think or feel. The attending cardiologist called in medical residents and fellows to show them that “this is what atrial fibrillation sounds like” through the stethoscope.

Referred to an electrophysiologist, I was put on a beta-blocker and warfarin. Given my young age and the perpetual nature of atrial fibrillation, I knew I was headed toward a cardiac ablation.

[For someone as young as Warren, it’s unthinkable to leave him taking dangerous A-Fib drugs for a lifetime (60 or 70 years). In addition, a catheter ablation was his most reasonable option with a high success rate in young people like Warren.]

Suffers Most from Mental and Psychological Effects

While I had few A-Fib symptoms, what I found hard to endure and most debilitating was the mental and psychological effects. I would ask myself:

‘Why is this happening to me and not anybody else?
Why can’t I go back to college and enjoy my freshman year with my friends?
Given all these circumstances, is my life worth living?’

These questions may sound stupid to a mature person in good mental condition. But that wasn’t me. Remember, I was only 18 years old and just starting college, and college students are prone to depression for various reasons. (See Seven Ways to Cope with the Fear and Anxiety of A-Fib)

My solution: Instead of staying home and pondering about these life problems, I decided to keep myself busy with activities, online classes, and occasional meet-ups with friends.

In hindsight, that helped tremendously.

My Catheter Ablation

It was roughly 3 months between my diagnosis and my ablation in March 2013. So, I only “knowingly” lived with A-Fib for a few months before my ablation.

The day of my RF catheter ablation came just as any other day. I had been admitted the night before. Except for not eating after 9 pm, I did nothing to prepare myself for it. I think the procedure lasted about 1 1/2 hours. I stayed in the hospital overnight.

As a child, I had had many surgeries, so hospitalization was not a big deal. (To keep this short, I’ll skip my childhood medical history.)

Post Ablation

After the procedure, I was almost always in sinus rhythm. But my atrial fibrillation would come back intermittently. Most episodes were really short with the frequency decreasing over time. [This is common during the three-month ‘blanking period’ following an ablation.]

However, because my heart rate was not well controlled and because of the risks of recurrences, I was put on diltiazem, a calcium channel blocker.

Because of my hypertension and high cholesterol (added risk factors of atrial fibrillation), I am also on Cozaar and a statin.

Now A-Fib-Free 

Since I started diltiazem, I’ve not had an episode…except one time after being under general anesthesia. The cardiologist believes that was a side effect of propofol [used to help you relax before and during general anesthesia for surgery].

It would be great if I could live without my various medications, but taking them, honestly, is not a big deal.

Lessons Learned

Emotionally Stronger and Healthier: I feel the entire A-Fib/ablation process has made me an emotionally stronger person. I also started to work out and take care of my own health more. (But that’s also a function of becoming more mature with age rather than the ablation alone.)

In the process, I have learned to enjoy and appreciate life in the way most people my age could never do.

I have learned to enjoy and appreciate life in ways others my age could never do.

Atrial Fibrillation―It Comes in a Package: By that I mean, cardiovascular disorders often come “packaged” together, often congenitally and genetically.

I’m trying to suggest that people with A-Fib/arrhythmia often have other cardiovascular risk factors. For instance, I have hypertension and high cholesterol and a family history thereof.

Moreover, cardiovascular diseases are also risk factors of diseases for other organs, such as the kidneys and liver.

My advice for younger patients diagnosed with Atrial Fibrillation:

Exercise: I would suggest that young adults work out more, at least 3 times a week for one hour each time.

Seek Help for Mental Health: For those suffering from A-Fib, make sure that you have a good attitude. Seek counseling if you have mental conditions from A-Fib.

Evaluate & Reduce Other Risk Factors:  Young A-Fib patients should also see general cardiologists to evaluate A-Fib related risk factors.

When young people get A-Fib, they could be living with it for possibly more than 50 years. Take actions to reduce your risk factors and take care of your body.

Positive Attitude Trumps All: I’m dealing with my ‘package’ of conditions. While getting rid of my ‘package’ once and for all might not be an option for me, I can choose to live with a positive attitude.

I welcome your emails.”

Warren Darakananda

Editor’s Comments:
We are most grateful to Warren for his frank discussion of how A-Fib affected him psychologically and emotionally. He was only 18 years old when diagnosed with A-Fib and just starting college. He’s learned the hard way how to develop a “positive attitude.”
Psychological Distress:  For Warren, the psychological effects were hard to endure, much more so than his physical symptoms.
Recent research indicates that “psychological distress” worsens A-Fib symptoms’ severity. For many patients the anxiety, fear, worry and depression can become debilitating.
To learn how to deal with the psychological aspect, see my article, Seven Ways to Cope with the Fear and Anxiety of A-Fib.
A-Fib Support Volunteers: I’m pleased to welcome Warren to our group of A-Fib Support Volunteers. He hopes to be a resource for those patients closer to his age. (He’s one of our youngest volunteers.)
We are blessed to have many generous people who have volunteered to help others get through their A-Fib ordeal. Most A-Fib Support Volunteers are not medical personnel. They come from widely different backgrounds. But you can be sure they care about you and understand what you are going through. Visit our A-Fib Support Volunteers page to learn more.

Personal Story: Urology Test Led to A-Fib Diagnosed at Age 66

Larry Stichweh tells us about his 8 year journey with Atrial Fibrillaiton. It all started with his high blood pressure.

“It was taking an increasing level of meds to keep my blood pressure in check. At a routine office visit, I suggested to my doctor that we should look at possible causes of my high blood pressure.

My doctor agreed, and as a starting point, sent me to an urologist to look for a kidney stenosis problem. The ultrasound proved negative, but the urologist listened to my heart and noted an irregular beat. I had no known prior history of heart problems.

The urologist sent me down the hall for an ECG with instructions to have the technician give the chart to me to take back to him. He took one look at it, took me to his office, and said he was admitting me to the hospital right then and there. He put me in a wheel chair (even though I felt no symptoms) and off I went.

He said I had no “P” wave and was in A-FIB. Thus, began my A-FIB history.” Continue reading Larry’s story.

Major Coumadin Problems, on Sotalol For 8 Years, Then Cryoballoon Ablation at Age 74

By Larry Stichweh, Lacey, WA, August 2017

Larry Stichweh, Lacey, WA

Many of the shared personal A-FIB experiences on describe a long and complicated path to a cure. But mine, not so much.

But it did involve these issues: a bad experience with Coumadin, effective long-term use of Sotalol (Sotalol becoming an important component of my blood pressure control), significant congestion side effect of Eliquis, and a single successful cryogenic PVI ablation with no complications.

I hope my story is more typical of those who experience A-FIB (except for the Coumadin issue).

High Blood Pressure for 20 Years

My story begins at age 66 in 2008. I am a retired chemical engineer and was living in Pensacola FL. I had been successfully treated for high blood pressure for at least 20 years, working progressively through many hypertensive drugs and drug combinations. Up to this point my blood pressure was controlled near 120/80.

Urology Test Led to A-Fib Diagnosed at Age 66

It was taking an increasing level of meds to keep my blood pressure in check. At a routine office visit, I suggested to my doctor that we should look at possible causes of my high blood pressure.

He took one look at my ECG, took me to his office, and said he was admitting me to the hospital right then and there.

My doctor agreed, and as a starting point, sent me to an urologist to look for a kidney stenosis problem. The ultrasound proved negative, but the urologist listened to my heart and noted an irregular beat. I had no known prior history of heart problems.

The urologist sent me down the hall for an ECG with instructions to have the technician give the chart to me to take back to him. He took one look at it, took me to his office, and said he was admitting me to the hospital right then and there. He put me in a wheel chair (even though I felt no symptoms) and off I went.

He said I had no “P” wave and was in A-FIB. Thus, began my A-FIB history.

Hospitalized 6 Days: Started Arrhythmic Drug

I do not know how long I was in A-FIB at that point as I did not recognize any symptoms except for a bit of fatigue. My best guess was less than two weeks prior to discovery. I spent 6 days in the hospital while I was introduced to the arrhythmic drug, Sotalol, which requires a few days of monitoring at the start to watch for undesirable reactions.

I do not know how long I was in A-FIB at that point as I did not recognize any symptoms except for a bit of fatigue.

I also began anticoagulation therapy which starts with injected heparin and then migrates to Coumadin.

After 6 days in the hospital I was feeling well (though bored) but still in A-FIB. I requested a electroconversion. During the prep and anesthesia, I self-converted [back into sinus rhythm] and was sent home to begin adjusting the Coumadin level.

Weeks Spent Adjusting Coumadin Dosage

Now the “fun” begins.  I left the hospital taking 160mg Sotalol/day and 5.0 mg Coumadin with an INR of about 2.5 on April 29, 2008.  I had to report to a “Coumadin lab” every few days while they adjusted the Coumadin dosage to the target INR level.

Here is the history of the adjustments, as prescribed by the clinic technician, working toward a target INR of 2.5:

Date    INR    Adjusted Coumadin mg/day

4/29     ~2.5     5.0 as discharged from hospital
5/2       4.1       4.0
5/8       4.3       4.4 I do not know why this increase was prescribed
5/16     3.8       4.0
5/30     3.6       3.0

[SSR: These INR levels are too high for someone on Coumadin.] I spent the better part of a month above the target of 3.0.

On June 3, 2016 I was sitting at my computer in the morning when I noticed my blood pressure increasing rather rapidly from my normal systolic of about 130mm to 200mm.

I had my wife drive me to the emergency room where I was monitored due to the high blood pressure, and they noted I had been taking Coumadin.

Back to Hospital with High Blood Pressure Crisis

By midafternoon I was sitting in the ER and noted my vision was fading out to all white. The dropping blood pressure brought the staff in to put my head down and feet up which brought back my sight and consciousness.  At this point the ER doctor said he had no idea what my problem was, and I was admitted to a hospital room. I seemed to be somewhat stabilized at this point but very weak.

That night a bowel movement was very large and resembled fresh asphalt which I informed the attendant of the next morning [sign of intestinal bleeding]. This information apparently did not make it into my record, a major oversight. No one ever asked about this possibility while I was there, and I was in no shape to think clearly.

The next three days I did not have the energy to sit up or eat any solid food. They ran many tests including a CT scan and frequent blood tests.

None of these produced any clue as to my problem.

That is until day four. After I had been drinking only water, my morning hemoglobin results came back at 7.0 (normal is 14) now that my blood volume was back to normal due to the water intake. I had lost 5 pints of blood.

My Small Intestine Bleeding Linked to Coumadin

At this point the several doctors on my case knew what to do, and three units of blood brought my hemoglobin up to 11.5. They concluded that the intestinal bleed had stopped on its own with the discontinuation of Coumadin and that I could be discharged.

With the discontinuation of Coumadin, the intestinal bleed had stopped on its own.

Poor Opinion of Hospital Care: This sequence of events does not reflect well on the hospital and staff and their record keeping. My wife was also not happy with the lack of communications with the cardiologist managing my case. I do not remember any discussions with any of the doctors.

A follow-up colonoscopy and endoscopy eliminated the back and front end leaving the small intestine as the default source of the bleed. At this point it was concluded that I should avoid Coumadin until such time as this problem in my small intestine is identified and corrected, if ever.

Switched to Aspirin: The newer anticoagulants, not requiring INR monitoring, were not yet available [in 2008]; so I was left on 81mg aspirin for anticoagulation.

Next 8 Years: Paroxysmal A-Fib Gets Worse

As time progressed my A-FIB was clearly paroxysmal with episodes lasting between 1 and 2 days with 8 episodes over the next 8 years. The interval between episodes ranged from 0.6 months to 22 months. This calculates out that I was in A-FIB only 1% of the time.

Symptoms were minimal, consisting of slight fatigue with the loss of the atrial pumping action and the noted irregular heartbeat.

I could not identify any thing that triggered or ended an A-FIB event. I always self-converted and had to pay attention to even note when the sinus rhythm returned.

When the last A-FIB attack lasted three weeks, it was time to consider an ablation.

Arrhythmic Drug: Sotalol dosage was adjusted between 160 and 240 mg/day with reductions when needed to increase the resting heat rate or increased as the A-FIB frequency and duration eventually began to increase.  Fortunately, this A-FIB frequency meant that anticoagulation therapy was likely of little value in my case. [Some say that clots can form and cause an A-Fib stroke in only 24 hours.]

A-FIB Frequency and Duration Increase: Sotalol and other antiarrhythmic drugs typically are effective for only a few years at most, but in my case, Sotalol worked for 8 years before the A-FIB frequency and durations began increasing.

When the last A-FIB attack lasted three weeks, it was time to consider an ablation at age 74.

Elects CryoBalloon Ablation at Age 74

By this time [2016] cryogenic balloon ablations had become readily available in major medical centers in the US, and I was now living in the Seattle area. This was a major improvement over the RF burning ablations for the Pulmonary Veins, the most common sources of A-FIB.

My local cardiologist referred me to Dr. Derrell S. Wells with the Swedish Heart and Vascular Clinic at Cherry Hill in Seattle. (I had noted his listing on the directory of doctors.)  My local cardiologist had an echocardiogram done and forwarded it to Dr. Wells who reviewed my echocardiogram and medical history. He concluded I was a good fit for a cryogenic PVI ablation.

My EP Skilled in Both CryoBalloon and RF Ablation Techniques

My left atrium was enlarged but still within the acceptable range. He could also do RF ablations at the same time if other active electrical sites were found.  Dr. Wells looked at my Coumadin adjustment experience and commented that it was no wonder I had a bleeding problem.

My EP could also do RF ablations at the same time if other active electrical sites were found. 

Surprisingly, there was only a 6-week waiting time between the initial appointment and the ablation procedure. The day before, I reported for x-rays and an MRI to create a three-dimensional model of my heart for use in the procedure. The clinic had at least two MRI units and at least one was a 3 Tesla unit.

Stopping Sotalol Causes Problems

Three days before the ablation I was to stop the Sotalol. (During the procedure, they do not want a drug suppressing any A-FIB tendency.)

Stopping the Sotalol proved to be a significant problem for me. Two days after stopping the Sotalol, I reported for the MRI and a checkup by Dr. Well’s nurse practitioner.

My heart rate was above 100, blood pressure was high, and I had the “shakes” so much that I could not sign my name in a recognizable script.

The nurse said if I thought it necessary, I could take a Sotalol which I did.  One hour later I was back to normal.

CryoBalloon Ablation: Successful 2.5-hour Procedure

The next morning, I was prepped for the catheter procedure.

Dr. Wells used conscious sedation, but I was totally unaware of anything during the 2.5-hour procedure. All four pulmonary veins were ablated using two freeze-thaw cycles for each vein.  Electrical isolation was confirmed.

No Significant Bleeding/No Complications: No other A-FIB sources could be identified, and an arrhythmic event could not be chemically induced. Total fluoroscopic time was 11.5 minutes, a relatively low time. No significant bleeding issues were experienced at the catheter insertion point. Dr. Wells said that my case was a “text book” case with no complications during the procedure.

Blood Pressure/Heartrate Alarm: Later that evening my blood pressure and heartrate increased significantly as I had not taken a Sotalol for 30 hours. I asked the nurse to give me 120mg of Sotalol which he did after consulting the on-call doctor. Again, that solved the problem within the hour.

I was discharged the following morning.

Most Patients Not on Sotalol for 8 Years: Dr. Wells said he had not seen a case where Sotalol had provided a significant contribution to blood pressure control, but then most patients have not been taking it for 8 years.

Recovery―Replacing Eliquis with Pradaxa

Over the next several months the Sotalol was gradually replaced by another blood pressure medication (Carvedilol added to Losartan and Torsemide).

Eliquis caused me significant congestion, trouble breathing, and wheezing. It was replaced by Pradaxa with no issues.

Eliquis was prescribed for at least three months after the ablation to avoid blood clots while the heart tissue healed. Eliquis caused me significant congestion, trouble breathing, and wheezing. It was replaced by Pradaxa with no further issues.

I should also note that I had been taking 20mg/day of Omeprazole for 6 years for gastritis which may have helped me tolerate the Pradaxa, but this is pure conjecture.

After One Year Still A-Fib Free

During the three months [blanking period] following the ablation I experienced no A-FIB events. But I did observe a few missed heart beats ranging from 1 to 10 that gradually diminished to zero.

There were no irregular heartbeats as experienced with A-FIB. After three months, I was given a wearable battery powered cardiac monitor for two weeks which was then mailed off for analysis.

Off Pradaxa: The results came back in a normal range, and Dr. Wells gave me permission to discontinue the Pradaxa. Almost one year later I continue to be A-FIB free.

Self-Monitoring of Blood Pressure & Pulse: I monitor my blood pressure frequently, and the unit I use will also detect an irregular heartbeat. I can also feel the pulse in my wrist. This takes about 5 seconds to do, requires no equipment and can be done anywhere and at any time. It was obvious when I was in A-Fib.

Lessons Learned:

I guess the point of my story is that even if your symptoms are minimal and paroxysmal, do not hesitate to consider an ablation if you begin moving toward persistent A-FIB.

Success Rate diminishes: As your A-Fib becomes more persistent, the lower your success rate of a permanent cure.

Don’t Delay Too Long: The rapid advances in ablation procedures over the last 20 years suggest delaying if possible, but not beyond the point of a diminishing probability of a successful cure.

Larry Stichweh

Editor’s Comments:
Larry’s Easily Cured Case: We’re grateful to Larry for sharing his A-Fib story of being cured by a single, short CryoBalloon ablation, which is similar to the experience of most A-Fib patients (unlike many of the stories in which tend to be unusual and often heroic).
Success with Sotalol: Larry had remarkable success with the antiarrhythmic drug Sotalol which also has beta-blocker properties.  But don’t count on any antiarrhythmic drug to control or eliminate A-Fib for 8 years. Most antiarrhythmic drugs tend to lose their effectiveness over time, as Sotalol eventually did for Larry.
Anticoagulants are Considered High Risk Drugs: Coumadin and all anticoagulants are considered high risk medications. They work by causing or increasing bleeding. Even though they are certainly preferable to having an A-Fib stroke, they carry their own set of risks.
Larry could have died from his internal bleeding. He will have to monitor and watch out for GI bleeding probably for the rest of his life.
But on the other hand, Larry was having A-Fib episodes longer than 24 hours which can cause clots and strokes. One of the most difficult decisions you and your doctor have to make is whether or not to be on an anticoagulant and which one to take. And that decision may change as you do.
Continued Monitoring: Larry will see Dr. Wells or his colleagues for at least once a year (but, like me, probably for the rest of his life).
He may want to make sure he doesn’t slip back into silent A-Fib, so he may use DIY monitors at home to check himself regularly.

In your 80s? Are You Doomed to a Life in A-Fib or Can You Still Have a Catheter Ablation?

If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs. You most likely can still have a catheter ablation. The research by Dr. Pasquale Santangeli is very hopeful and encouraging.

Study of Octogenarians Who Had a Catheter Ablation (PVI)

Dr. Pasquale Santangeli and his colleagues at the Texas Cardiac Arrhythmia Institute in Austin, TX examined data from 103 octogenarians who had an RF catheter ablation between 2008 and 2011. They compared this older group to younger patients who underwent the same procedure.

 If you’re in your 80s, you’re not automatically doomed to a life in A-Fib and on A-Fib drugs.

• There was no difference in the rate of success between the octogenarians and the younger group (69% vs. 71%).

• The rate of procedure-related complications was also not significantly different between the two groups, even when looking at different types of A-Fib such as paroxysmal and non-paroxysmal A-Fib.

• Octogenarians with paroxysmal A-Fib had more non-pulmonary vein trigger sites, and consequently required longer procedural time to effectively isolate such non-pulmonary vein areas. (Dr. Santangeli suggested a hypothesis that the underlying pathology of A-Fib in older patients might be different from younger patients.)

In practice, octogenarians have been largely excluded from clinical trials of catheter ablation. Current guidelines are also very conservative, because there has been a lack of adequate clinical studies in this area. Dr. Santangeli’s report is a step in the right direction.

When Old Isn’t Necessarily Old

In the real world old isn’t necessarily old. People in their 80s may indeed have ‘excellent functional and health status” which would make them good candidates for a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.

You can still have a catheter ablation but you need to find an EP Experienced in Non-PV Triggers.

After all, a catheter ablation is a non-invasive procedure. It isn’t like open heart surgery which is incredibly taxing and physically demanding. You don’t have to be a ‘Johnny Atlas’ muscleman to have a catheter ablation. Most healthy 80-year-olds aren’t so frail that they can’t have a catheter ablation.

In your 80s? Find an EP Experienced in Non-PV Triggers

If you’re in your 80s, you most likely can still have a catheter ablation. But, you need to find the right electrophysiologist (EP).

Make sure you select an EP with a proven track record of finding and isolating non-PV triggers. (Dr. Santangeli’s research found that octogenarians have more non-pulmonary vein trigger sites.) Some EPs can’t or won’t make the extra effort to map and ablate non-PV triggers.

(I’ve read O.R. reports where the patient was still in A-Fib after the EP had ablated their PVs. Instead of trying to map and ablate non-PV triggers, the EP simply electrocardioverted [shocked] the patient back into sinus rhythm. After a short time, the patient went back into A-Fib.)

Questions to Ask a Prospective EP

When interviewing a prospective EP, ask:

 “What do you do if I’m still in A-Fib after you’ve ablated my pulmonary veins?” (You want a reply such as “I use mapping to search for non-PV triggers in other areas of the heart”.)

We are indebted to Dr. Santangeli and his colleagues for showing that octogenarians can have a successful, safe ablation, and shouldn’t be excluded from a catheter ablation simply on the basis of their age.

To learn more: read my related article: FAQs A-Fib Ablations: Is 82 Too Old for a PVA?  

References for this article

Does a Successful Catheter Ablation Have Side Benefits? How About a Failed Ablation?

Are there additional dividends from a successful catheter ablation for A-Fib—beyond being back in normal sinus rhythm (NSR)? Research says, yes!

Additional Benefits of Successful Catheter Ablation

“The benefit of catheter ablation extends beyond improving quality of life…If successful, ablation improves life span,” says, lead author Dr. Hamid Ghanbari, an electrophysiologist at U.of Mich. Frankel Cardiovascular Center.

Illustration of RF ablation

His comments are based on a study that examined 10 years of follow-up medical data on over 3,000 adults who received RF catheter for paroxysmal or persistent atrial fibrillation. Researchers found that staying in normal sinus rhythm (NSR) was associated with a 60% reduction in the expected rate of cardiovascular mortality (risk of death from stroke and other cardiovascular events).

In another study (Anselmino), a meta-analysis of 26 studies involved 1,838 A-Fib patients who had undergone a catheter ablation. Post-ablation follow-up averaged 23 months. Examining the patient follow-up data, researchers found a significant 13% improvement in left ventricular ejection fraction (EF), i.e., the heart’s blood pumping efficiency.

In addition, there was a significant reduction in the number of patients who formerly had an ejection fraction of less than 35% (more patients improved their EF ratio out of the life-threatening range). Blood pressure levels were also improved.

Summary of Research Findings: These studies reveal some of the real benefits to patients after a successful catheter ablation that go beyond being in normal sinus rhythm (NSR):

• improved quality of life
• significantly lower risk of cardiac-related mortality
• better heart pumping efficiency for more patients (ejection fraction, EF)
• improved blood pressure levels

You may ask, do these side-benefits depend on the catheter ablation eliminating the patient’s A-Fib?

Ever Wonder If There Are Benefits from a Failed Ablation?

Catheter ablation from Cleveland Clinic

VIDEO: Catheter ablation, Cleveland Clinic

Researchers have studied the follow-up data of failed ablations and found a few ‘side’ benefits.

A clinical trial (Pokushalov) showed that, when ablation fails to eliminate paroxysmal atrial fibrillation, a second try is more successful in returning the patient to sinus rhythm than medication alone; it also slows the progression from paroxysmal A-Fib to persistent A-Fib.

In addition, some patients found their A-Fib symptoms were less intense or shorter in duration. (Might be attributed to an improvement in left ventricular ejection fraction.)

Other patients found they could take certain medications that prior to their ablation had been ineffective.

Summary of Research Findings: These studies reveal some of the real benefits to patients even if their catheter ablation doesn’t return them to normal sinus rhythm:

• second ablation is more successful than medication alone
• second ablation slows progression from paroxysmal to persistent A-Fib
• symptoms were shorter or less intense
• certain medications worked that didn’t work before

A catheter ablation can profoundly change one’s life, even if you need a 2nd ablation.


A catheter ablation can profoundly change one’s life, even if you need a 2nd ablation. 

So, either way, a catheter ablation offers benefits to Atrial Fibrillation patients. Even if you need a second ablation (or a third), know that you may still reap substantial benefits from the previous “failed” ablation.

For more about the benefits of ablation, see Live Longer―Have a Catheter Ablation!

References for this article

A-Fib Recurrence Post Ablation: Should you Have a Second Ablation? or Anti-Arrhythmic Drug Therapy?

Evgeny Pokushalov, MD, PhD

E. Pokushalov, MD, PhD

It’s disappointing when your heart doesn’t return to normal sinus rhythm (NSR) after your catheter ablation. What’s your next step, your follow-up treatment?

In his study, researcher Evgeny Pokushalov asked several related questions:

“If A-Fib recurs after a patient’s initial catheter ablation procedure, which is the better follow-up treatment? A second catheter ablation or taking antiarrhythmic meds?”

The Three-Year Study

In this study, 154 paroxysmal A-Fib patients who had a failed ablation were divided into two randomized groups.

A catheter ablation can profoundly change one’s life. And, even if you need a second ablation one.

The first group had a second ablation, the other group was put on antiarrhythmic drug therapy (AADs). The two groups were monitored by an implantable loop recorder, followed for three years, then compared.

Study Results

After three years, researchers found A-Fib present in 5.6% of the re-ablation group. In the antiarrhythmic drug group, 18.8% had A-Fib.

A second significant finding was the rate of paroxysmal A-Fib progressing to ‘persistent A-Fib’.  The re-ablation group had a progression rate of 4%, while the progress to “permanent A-Fib’ was 23% in the drug therapy group.

Expected and Unexpected Findings

I had expected (and it was confirmed) that the group getting a second ablation would have better results than the group on antiarrhythmic drug (AAD) therapy.

…progress to permanent A-Fib was 23% in the drug therapy group.

Many studies have documented this when patients undergo their first ablations vs AAD therapy.

What I didn’t expect was the rate of progression to persistent A-Fib in the second group. Nearly one-fourth (23%) of patients taking antiarrhythmic drugs progressed to persistent A-Fib after a failed ablation!

The Message is Clear 

To reduce your risk of progressing to persistent A-Fib, if you have a failed ablation, you are best served getting a second ablation rather than relying on antiarrhythmic drugs.

Are there benefits from a catheter ablation even when the patient’s A-Fib has not been eliminated? Yes! To learn more, see: Are There Benefits from a Failed Ablation? Yes!

References for this article

Considering a CryoBalloon Ablation? Seek an EP also Skilled in RF Ablation Techniques

Recently a patient, still in A-Fib after a CryoBalloon ablation, sent me their Operating Room (O.R.) report which is a blow-by-blow account of the EP’s actions during the procedure.

In my review of their report, after cryoablation of the Pulmonary Veins (PV), the patient was still in A-Fib. It appears the EP did not to make any attempt to map and isolate non-PV triggers. Instead the EP simply electrocardioverted the patient to return him to normal sinus rhythm (NSR). This may work in some cases, but for this patient the ablation was a failure. 

Your O.R. report is a historical record of the EP’s actions during your ablation.

When Considering a CryoBalloon Ablation

When selecting your electrophysiologist (EP), be cautious. For the best results, you want an EP who is not only experienced with CryoBalloon, but also, when needed, can use RF to map and isolate non-PV triggers.

Stay away from EPs who only do CryoBalloon ablation. Some EPs with little or no expertise with RF catheter ablations are now doing CryoBalloon ablations because they’re easier (i.e. less demanding) and faster to perform (more lucrative).

Seek an EP with Both Sets of Skills

Dr-Ali-Sovari, EP Lab, Oxnard, CA at

Dr Ali Sovari and nurse, EP Lab, Oxnard, CA (procedure observed and photographed by Steve Ryan)

A dual skill-set approach is supported by a study of about 75 paroxysmal A-Fib patients undergoing their first CryoBalloon ablation. Researchers found about 30% of patients required the additional use of RF focal lesions to achieve isolation (to restore normal sinus rhythm).

Most RF-experienced EPs who are now doing CryoBalloon ablations, have the ability and skill to use focal point RF techniques, as needed, to make you A-Fib free during your CryoBalloon ablation.

What Patients Need to Know

In the patient’s case above, an EP experienced in mapping and making RF lesions, could have used these additional skills and tools to locate and ablate non-PV sources of A-Fib signals, and hopefully return the patient to normal sinus rhythm (NSR) at the conclusion to the ablation.

To find the right electrophysiologist (EP) for your CryoBalloon ablation, seek out RF-experienced EPs by asking these probing questions:

 “What do you do if I’m still in A-Fib after you do the CryoBalloon ablation? Will you use RF focal lesions to achieve isolation?”

To learn more about these research findings see By Combining RF and CryoBalloon Ablation Techniques, Do Success Rates Increase?

References for this article

My Top 7 Articles about Catheter Ablation for Atrial Fibrillation

Catheter Ablation techniques are achieving success rates of 70%-85% in making patients A-Fib-free and up to 90% success when a second ablation procedure is required.

Side Benefits: A successful catheter ablation also reduces development of early onset dementia and returns your risk of stroke to that of a person without A-Fib. Catheter ablation is currently the best technique available for “curing” A-Fib.

You don’t have to live the rest of your life on medication. To seek your A-Fib cure, review these articles to learn more about catheter ablation:

1. A-Fib Research: Live Longer―Have a Catheter Ablation
2. Weight Loss Key to Reverse Atrial Fibrillation, Improve Ablation Success
3. Considering a Catheter Ablation? When Choosing Your Doctor—Know EP’s Complication Rates
4. Chances of A-Fib Recurrence After Successful Catheter Ablation
5. What are the Risks Associated with a Pulmonary Vein Ablation Procedure?
6. A-Fib Ablations: Recurrence (Re-connection) Explained
7. The Evolving Terminology of Catheter Ablation

VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected. Cardiologists from the Cleveland Clinic describe the catheter ablation procedure for the treatment of atrial fibrillation, what it is, how it’s done and what results can be expected from this surgery.

Excellent animations: showing A-Fib’s chaotic signals, and the pattern of ablation scars around the openings to the pulmonary veins. By the Cleveland Clinic (4:00 min.) Go to Catheter Ablation video.

Silent Persistent A-Fib: A Proactive Patient’s 3-Year Journey to Burden Relief

By Frances E. Koepnick, Athens, GA, June, 2017

Frances, now A-Fib free after 3 yrs.

 “I was diagnosed with atrial fibrillation (A-Fib) in April 2014, at age 69, while undergoing a pre-operative physical examination prior to hip replacement surgery. This was a surprising development since my A-Fib was completely “silent” with no symptoms.

My A-Fib was diagnosed as being ‘persistent’ rather than ‘paroxysmal’. These two forms of A-Fib are quite different. However, both types of A-Fib are usually treated initially with prescription drugs. I was given the beta blocker atenolol to reduce my heart rate and the anti-coagulant Eliquis to prevent the formation of blood clots.

Family History of Atrial Fibrillation

Unlike many other stories on, I was familiar with Atrial Fibrillation. I am the third person in my family with A-Fib after my mother and older sister. However, they both had paroxysmal A-Fib while I was diagnosed with persistent A-Fib.

On-going studies indicate that there may be a genetic link to A-Fib.  Consequently, if someone in your immediate family has been diagnosed with A-Fib, then your risk of developing it in the future may be increased.”

Six Cardioversions: Not a Long-Term Solution

Eventually, I underwent a total of six cardioversions in an attempt to return my heart to normal sinus rhythm. Three of these procedures were electrical cardioversions and three were by means of intravenous drugs. I soon learned that cardioversion is rarely effective for maintaining normal sinus rhythm over a significant period of time.

Consequently, I did not consider it to be a long-term solution for my A-Fib.

The First Two Cardiologists Advised: ‘Just Take Your Medications and Live with A-Fib’―No! No! No!

I eventually consulted a total of five cardiologists―three in the state of Georgia, one in Manhattan and one in Bordeaux, France. I have a background in anatomy/physiology as well as microbiology, so I asked a lot of questions and managed to irritate several physicians.

“I eventually consulted a total of five cardiologists. I asked a lot of questions and managed to irritate several physicians.”

The advice of the first two cardiologists was to “just take my medications and live with A-Fib”.

If your cardiologist recommends this treatment regimen, I urge you to get a second, third or even fourth opinion.

More Interviews: Three Electrophysiologists & Lots of Questions

After my first electrical cardioversion in March 2015, my heart remained in normal sinus rhythm for only 12 hours. At that time, I had been in persistent A-Fib for one year, and was re-classified as long-term persistent A-Fib. That motivated me to pursue a catheter ablation.

I ultimately discussed an ablation procedure with three different electrophysiologists and consequently learned to ask lots of questions such as:

  • What is the percentage rate of successful ablations performed by this cardiologist/electrophysiologist?
  • What is the risk of serious complications?
  • How many ablations does this cardiologist/electrophysiologist perform at his/her facility annually? (My opinion is: “the more, the better”.)
  • What type of instrumentation is used for electrical cardiac imaging? (My opinion is the CardioInsight or ECGI/ECVUE imaging system; FDA-approved for the USA in February 2017.)

I finally located a cardiologist/electrophysiologist (EP) at a regional medical center who performed ablations for long-term persistent A-Fib.

Look for the Best EP―and Ablate Sooner Rather Than Later

At this point I had been in A-fib for 17 months. The first 7 months of this time frame was necessary due to my need for two total hip replacements which were performed 5 months apart. However, the additional 12 month delay was due to my procrastination in seeking a third opinion from another EP.  That was definitely a mistake. This additional delay reduced my success rate for a successful first ablation to approximately 65% and it also increased the chance that I might need a second ablation in the future. (I anticipated I might need a 2nd ablation because of this.)


“…This delay of treatment reduced my chance of a successful first ablation to approximately 65%. I anticipated I might need a 2nd ablation because of this.”

Ablation for Persistent A-Fib is More Difficult

There are many competent electrophysiologists in the USA who have been successful with ablations for paroxysmal A-Fib. However, ablations for persistent and long-term persistent A-Fib are more difficult, require a higher level of expertise, and are performed less frequently in the USA.

CHU Hopitaux de Bordeaux logoBordeaux, France: Consequently, in September, 2015 I decided to have my ablation for long-term persistent A-Fib performed in Bordeaux, France. I chose this location because it’s internationally known for its cardiologists/electrophysiologists as well as for its use of the computerized CardioInsight or ECGI imaging system. [They cured Steve Ryan’s A-Fib back in 1998.]

This arrhythmia group is headed by Dr. Michel Haissaguerre and Dr. Pierre Jais, and they perform ablations for paroxysmal, persistent and long-term persistent A-Fib. Of course, French citizens are first priority for admission, but out-of-country patients can be wait-listed.

Pierre Jais MD

Fran’s EP: Pierre Jais MD

Not Covered by My Insurance: I do need to mention that the decision to travel to Bordeaux, France, was financially significant. My medical treatment was not covered by insurance.

The Hopital Haut Leveque-Cardiologique in Bordeaux is not an impressive building. It was most likely built in the 1970s, the patient rooms are not air conditioned, and the parking lot is gravel rather than pavement. However, the French government obviously invests their health care funds in medical research, excellent physicians, quality hospital staffing, and state-of-the-art medical equipment.

“The hospital staff speak English, but I did purchase an English/French app with medical terminology for my smartphone.”

The physicians and most of the hospital staff speak English, so there really isn’t a significant language barrier problem. I did purchase an English/French app with medical terminology for my smartphone, and it was helpful on occasion. [In Bordeaux they have broken ground on the new LIRYC Institute which is intended to become one of the premier research institutions in Europe.]

Difficult Six-Hour Ablation at Bordeaux, then Electrical Cardioversions

My first ablation by Dr. Pierre Jais was a difficult procedure requiring six hours for completion. [Not only were her Pulmonary Vein openings isolated, but in addition, non-PV triggers were identified, mapped, and isolated using the CardioInsight ECGI mapping system.]

Fran wearing the mapping vest.

During the three-week time period following this ablation, two electrical cardioversions were also required. This was later explained to me by Dr. Jais as the interior of the atria needed to heal sufficiently so that scar tissue would successfully block abnormal electrical signals.

After this ablation, I continued to take the anticoagulant Eliquis and was also put on the anti-arrhythmic drug amiodarone for six months.

Normal Sinus Rhythm for 11 Months, then Atypical Flutter

I knew at the time of my first ablation that I most likely would require a second ablation due to my predicted one-year success rate of 65%.

My heart actually stayed in normal sinus rhythm (NSR) for a total of 11 months. Then I experienced three episodes of atypical atrial flutter over a two-week period, and each of these episodes resulted in an admission to the emergency room. After three intravenous drug cardioversions, I was placed back on amiodarone to maintain a normal sinus rhythm.

Suspected Sleep Apnea

After my third ER admission, I suspected that these episodes might have been triggered by obstructive sleep apnea (OSA). I was waking up during the night with an extremely uncomfortable dry mouth even though my head was elevated while sleeping.

I consulted my dentist, and he referred me to a cardiologist/sleep specialist who ordered a sleep study. This study confirmed that my OAS was “severe” during periods of rapid eye movement sleep (REM).

Sleep Apnea and A-Fib: I would like to emphasize that OSA is a significant “trigger” for A-Fib. A recent study found that 43% of individuals with A-Fib also had a diagnosis of OSA.

“I suspected that these episodes might have been triggered by obstructive sleep apnea (OSA), a significant “trigger” for A-Fib. Of all A-Fib patients 43% are also diagnosed with OSA.”

This means that all individuals diagnosed with A-Fib need to be screened with a sleep study. If OSA is confirmed, it needs to be addressed immediately so that any future treatment for A-Fib is not compromised.

OSA can be controlled by continuous positive airway pressure (CPAP) machines whereby you wear a face mask at night when sleeping. I decided instead to have a custom oral appliance (FDA-approved TAP3) made by a sleep dentist. This oral appliance prevents my lower jaw from moving out of position when sleeping and thereby ensures that my airway remains open.

Second Ablation by Dr. Vivek Reddy Using CardioInsight ECGI

Dr. Vivek Reddy, Mt Siani Hospital

Dr Vivek Reddy, Mt Sinai Hospital

My second ablation was performed by Dr. Vivek Reddy at Mount Sinai Hospital in Manhattan, New York in March 2017.

I had been referred to Dr. Reddy by my doctors in Bordeaux. It was fortuitous that Mount Sinai Hospital had just obtained the FDA-approved CardioInsight (ECGI) imaging system which was previously only available in Europe.

The physicians, staff and facilities at Mount Sinai Hospital are absolutely excellent. The arrhythmia group there is headed by Dr. Reddy, and I found him to be professional, personable and comfortable answering my questions.

My second ablation was another difficult, six-hour procedure, but ultimately successful. [If interested in Dr. Reddy’s O.R. Report on Frances’ ablation, see my comments below.]

I recommend that you go online to the Mount Sinai Hospital website and then watch short informative videos on A-Fib which are presented by Dr. Reddy himself. See What Do I Need to Know About Atrial Fibrillation? (21:29).

Success & Lessons Learned

My 3-year journey with A-Fib has included numerous cardioversions, two ablations and a belated diagnosis of underlying obstructive sleep apnea (OSA).

It’s now about three months since my second ablation, and I am doing well. I no longer am taking the anti-arrhythmic drug amiodarone, but continue on the anticoagulant Eliquis.

My recommendations:  Look locally, regionally, nationally and perhaps internationally in order to identify the best option for a successful ablation. (Yes, consider traveling to find the best EP for you.)

It is also important to seek an ablation sooner rather than later as a delay may decrease your chance of a successful procedure.

 Yes, consider traveling to find the best EP for you…seek an ablation sooner rather than later, a delay may decrease your chance of a successful procedure. 

Seek up-to-date information : I highly recommend the website, for up-to-date information on A-Fib. This website is run by Steve Ryan, Ph.D. and―although he is not a medical doctor― he is an A-Fib expert who explains A-Fib in terms readily understood by the average person.

Steve also attends the AF International Symposium held annually in the USA, and his synopses of conference presentations contain the latest in A-Fib research. Steve was and continues to be my A-Fib coach.

Smartphone app: Finally, I recommend the AliveCor Kardia device ($99) and app for smartphones. This app determines your heart rate in beats per minute (BPM) and also records a 30-second electrocardiogram (ECG) using two electrodes attached to the back of your phone. Kardia’s software interprets your ECG as “normal” or as “possible A-Fib”, and you can email a copy of an ECG directly to your cardiologist. [Also see our 2016 Update: AliveCor Kardia Review by Travis Van Slooten]

I welcome your email,
Frances Koepnick

Editor’s Comments:
We’re most grateful to Frances for her story. She’s a great example of a proactive patient. When told to ‘just take her meds and live with A-Fib’, she said NO! Even though she was relatively symptom-free, she knew how destructive A-Fib can be over time.
Don’t Just Live in A-Fib: Leaving patients in A-Fib overworks the heart and leads to remodeling and fibrosis which increase the risk of stroke, and also doubles the risk of developing dementia. For more read: ‘Drug Therapies’: Rate Control and A-Fib Doubles Risk of Dementia. If you hear someone tell you to just live with A-Fib, get a second opinion (or third, or fourth!).
Educate Yourself About A-Fib―Be Proactive: Frances knew she would be a more difficult case to fix. She researched who were the best EPs for her case. She asked all the right questions of the EPs she interviewed. (See Selecting a New Doctor? 10 Questions You’ve Got to Ask.) She even went to Bordeaux, France, on her own dime.
Find the Best EP You Can: All Electrophysiologists are not equal. Like Frances, don’t just settle for the nearest EP. Consider traveling to the best, most experienced EP you can afford, particularly if you have progressed to persistent A-Fib which is harder to fix. (See Finding the Right Doctor for You and Your A-Fib.)
Silent A-Fib: If You’re 65 or Older, Get Yourself Tested: Frances is lucky. She could have easily been one of the 25% of stroke victims who only discover their silent A-Fib after having a stroke. Everyone 65-years-old or older, should be tested for silent A-Fib.
Sleep Apnea: Most EPs today will insist you get tested for sleep apnea before performing a catheter ablation. Why? Patients with untreated sleep apnea have a greater risk of their A-Fib reoccurring even after a successful ablation. Also, for a lucky few, just getting rid of sleep apnea restores them to normal sinus rhythm (NSR). To learn more, see Sleep Apnea: When Snoring Can Be Lethal
CardioInsight ECGI/ECVUE System: The CardioInsight ECGI/ECVUE mapping system is probably the most significant, game changing improvement in mapping A-Fib, particularly for people with persistent A-Fib. To learn more, see Bordeaux New ECGI Ablation Protocol—Re-Mapping During Ablation.
Special 12-page report by Steve S. Ryan, PhD

FREE 12-page Report

Frances’ O.R. Report: Using the CardioInsight system, Dr. Reddy found 5 A-Fib drivers in Frances’ atria. (In typical persistent cases, 4 driver regions are usually identified. 7 drivers is the maximum found in more difficult cases.) (For you technical types, the 5 A-Fib drivers were found: at the base of the Left Atrial Appendage (LAA), the Ostium of the Coronary Sinus (CS), the posterior Left Atrium (LA), the Right Atrial Appendage (RAA) and the lateral Right Atrium (RA).)
When Dr. Reddy ablated at the base of the LAA, Frances’ A-Fib terminated. (That’s the ideal result when A-Fib terminates during the ablation.) But then Dr. Reddy checked to see if there were any other regions in her heart producing A-Fib/Flutter signals. By pacing her heart, he was able to induce Atrial Flutter (CL 380msec). Using activation mapping, he found the re-entry atrial flutter circuit was coming from the anterior inferior RA. Ablating this area terminated her Flutter.

For more about O.R. reports, see my free report: How to Read Your Operating Room Report.

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Return to: Personal A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Saturday, July 22, 2017


Now A-Fib Free: A Personal A-Fib Story 23 Years in the Making

It’s been a 23-year ordeal for Charn Deol who’s from Richmond, British Columbia, Canada. He was 43 in August of 1993 when he was aware of a few skipped heartbeats. He had just returned to Canada after working for years in Southeast Asia. A week later, the irregular heart beating got worse in duration.

Personal A-Fib story by Charn Deol, BC, Canada at

Charn Deol, BC, Canada

At the same time, Charn’s story is complicated by two other medical problems. First, simultaneous with the start of his A-Fib, a dull aching pain started in the left chest region the size of a 50-cent piece. Second, he was discovered to have very high levels of mercury in his blood.

Mercury Cleared, Atrial Fibrillation Stops!

By 2000, through chelation therapy treatments, the mercury was finally out of his system. And surprise! His atrial fibrillation stopped too. (It is known mercury can concentrate in nerve tissue.) While it’s only a correlative relationship―mercury out of system―his atrial fibrillation did stop.

For 10 years He had No Atrial Fibrillation

In 2010, while starting a hike, the atrial fibrillation began again. The A-Fib would last 6-8 hours and occur an average of 2 times per week. He was immediately tested for heavy metals again…continue reading Charn’s A-Fib story…

Now A-Fib Free: A 23-Year Atrial Fibrillation Ordeal, Trial, Tribulations and Recovery

By Charn Deol, Richmond, British Columbia, Canada, May 2017
Personal A-Fib story by Charn Deol, BC, Canada at

Charn Deol, B.C., Canada

My medical issues with atrial fibrillation started when I was 43 in August of 1993 when I was aware of having a few skipped heartbeats. I had just returned to Canada having been working extensively for the last few years in Southeast Asia. About a week later, the irregular heart beating got worse in duration.

At the same time, a dull aching pain started in the left chest region the size of a 50-cent piece.

A-Fib Drugs Don’t Work, Chest Pain Condition Worse

Upon being sent to a heart specialist in September 1993, numerous drugs were prescribed to keep my heart in rhythm (digoxin, flecainide, sotalol). They did not work, some had serious side effects, and every few days I would go into atrial fibrillation.

The atrial fibrillation happened once or twice per week and lasted from a few hours to 24 hours. Then it would stop on its own, and the heart would go into normal sinus rhythm.

Second medical condition: At the same time, the very centered pain in the upper left chest area kept getting worse and added to the debilitation of daily life. These medical conditions started my long journey to find relief (cure) from two medical conditions that were not being controlled or cured by conventional medical treatments.

Alternative Healthcare Practitioners―India & China, Too

In my search for a cure(s), I met a family practitioner and other medical and alternative specialists who used treatment protocols that could be labeled ‘experimental’ or ‘out of the box’, as they say.

I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.

While discovering alternative medical treatments in 1994, I also went to India for Ayurvedic treatment [one of the world’s oldest holistic healing systems] and even to China for treatment. Most alternative (non-allopathic) medical practitioners look at the body as an interconnected processing unit and believed in my case that the pain in the left chest and the atrial fibrillation were connected. This was not the thinking of the allopathic doctors, so I was all mixed up as to what was going on in my body. This can be psychologically very distressing if you do not have a strong family/friend support network.

Having been to a multitude of healthcare practitioners, numerous chiropractors, massage therapists and other more esoteric healthcare practitioners (100s over the 23 years), there was no resolution to my medical condition.

Encainide Drug Therapy: Up and Out

The heart specialist that gave me sotalol [an antiarrhythmic drug] in 1995 gave me a dose that dropped the heartbeat to 30 beats per minute putting me into the emergency room, but the drug had no effect on my atrial fibrillation.

In 1996 seeing my third cardiologist, I was put on a drug called encainide [also an antiarrhythmic drug], to be used on an as needed basis [pill-in-the-pocket].  It worked and would stop my atrial fibrillation in approximately 20 minutes.

But it had no effect on the chest pain which was getting worse now with a pain spot in the left shoulder blade area also the size of a 50-cent piece having started out of nowhere.

Encainide is a class Ic antiarrhythmic agent. It is no longer used because of its frequent proarrhythmic side effects.

About 6 months after starting on the encainide, one of my friend’s son with a heart condition since childhood passed away. And I was told he had just been started on a new drug for him called “encainide” along with “sotalol”. The same cardiologist had been providing this drug free of charge to me, so I was pleased that it worked for me and cost me nothing.

The problem I found out was that it was illegal for the cardiologist to prescribe this drug because it had killed too many people. When he got caught, then encainide was no longer available. (Encainide is a class 1C antiarrhythmic drug no longer used because of its frequent proarrhythmic effects.)

Chelation for Very High Levels of Mercury

I had the highest level of mercury ever seen by the lab in any of their patients.

While all the above was going on, I was tested for heavy metals through urine analysis. It was discovered that I had the highest level of mercury ever seen by the lab in any of their patients (7400 nmol/dl). So I started protocols to take the mercury out of my body using chelation treatments with EDTA and then DMPS and DMSA (metal chelators).

At the same time, my other medical practitioners had me on oral and IV multivitamins and mineral protocols.

Mercury Cleared, Atrial Fibrillation Stops!

By 2000, the mercury was finally out of my system and my atrial fibrillation stopped! It is known mercury can concentrate in nerve tissue. While only a correlative relationship―mercury out of system―my atrial fibrillation did stop.

Chest Pain Condition Worse than Ever

From 2000 to 2010 I had NO atrial fibrillation. But the chest pain condition did not stop, and it got worse.

From 2000 to 2010 I had no atrial fibrillation. But the chest pain condition did not stop, and it got worse extending into my gut region. All medical protocols tried could not alleviate this pain, nor was any etiology discovered as to what was the underlying cause of the pain condition.

Thanks to my resiliency, I was still able to go hiking, skiing, travel and work part-time on my own schedule. But it took great perseverance.

After 10 Years A-Fib Returns―and Heavy Levels of Lead (This Time)!

In 2010, while starting a hike, the atrial fibrillation began again. The A-Fib would last 6-8 hours and occur an average of 2 times per week.

I was immediately tested for heavy metals again, and this time I had high levels of lead, not mercury. Even with thorough investigations of potential sources for this lead contamination in my body, no source was discovered. We worked (and continue to work) on getting these lead levels down (I had no high lead levels back in the 1990’s when tested―only mercury).

Amiodarone Bad Side Effects

I again began doing alternative treatments to deal with the atrial fibrillation and the pain condition, nothing worked. I went to China again for treatments, IV EDTA infusions again, etc., but the pain persisted at high levels and the atrial fibrillation kept getting worse.

A new cardiologist put me on a new drug called amiodarone. This drug lead to paranoia. This is another cardiologist I dropped.

In 2012, I saw a new cardiologist who put me on flecainide again. And when it did not work, he provided me with a new drug called amiodarone. This drug lead to paranoia and left me with an epididymitis in my right testicle which I suffer from to this day. (Epididymitis is inflammation of the tube at the back of the testicle that stores and carries sperm.) He had no compassion for my dilemma. This is another cardiologist I dropped.

Ablation in Vancouver, B.C. Fails―A-Fib Worse and More Chest Pain

By late 2014, the atrial fibrillation was occurring on average every second day and lasting 24-38 hours.  My next cardiologist sent me to the Atrial Fibrillation clinic in Vancouver where I was evaluated by an electrophysiologist. The A-Fib was very debilitating, so I was ready for surgery.

VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected

WATCH A VIDEO: Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected (4:15)

I asked for the most experienced electrophysiologist at the clinic to do the surgery. I waited an extra 3 months for the surgery because this highly qualified electrophysiologist was in so much demand.

Finally, in November 2015 I had the ablation therapy (it took approximately 2.5 hours). I came out of the surgery worse than ever. The atrial fibrillation did not stop, and the pain was worse than ever in my left chest, left shoulder-blade and gut regions.

AV Node Ablation & Pacemaker?―No! No! No!

The electrophysiologist wanted to wait for the 6 month recuperation period after the ablation therapy to see if I would go into regular sinus rhythm. By September 2016 (9 months later), I was worse than ever. In November, I saw my electrophysiologist under the impression that he would do another ablation treatment, since I was told and with my own research had confirmed that ablation treatments may be required for up to four times for the treatment to work.

This “top” electrophysiologist recommended I have a pacemaker put in and the AV node be ablated instead, so that the pacemaker could take over the regular beating of the heart. I asked the electrophysiologist why not do further ablation treatments as per the standard practice. He said if that is what I wanted, he would do another ablation. This was quite disconcerting―I am relying on his extensive knowledge to help me in a field where I am no expert. We agreed to set up a surgical date for a second ablation on December 12, 2016.

My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital.

Upon leaving the office and arriving home, I informed my wife of the unpleasant appointment I had with the electrophysiologist, especially his lackadaisical attitude towards my serious heart condition. As a patient, the relationship is somewhat like that of a child with a parent. The patient is naïve, scared, distraught and looking for a path of reassurance from the medical profession. This was not the case in this situation.

This is when “gut instincts” come into play. My gut said to ‘no longer trust’ this supposed best electrophysiologist at the hospital and search for an alternative path. (And I canceled my December 12, 2016 scheduled ablation.)

Counseling with Steve Ryan

Having been a reader of Steve Ryan’s website, I reached out to him and agreed for him to become my advocate and provide me with advice on how to deal with my current concerns over either going along with having a pacemaker placed in my chest along with ablation of the AV node OR to try a second ablation. Steve recommended a second ablation and the Bordeaux Clinic―it was too early to place a pacemaker/ablate the AV node at this stage.

Following this detailed discussion with Steve, I spoke with my wife and got a hold of the Bordeaux Clinic in France on December 2, 2016. With some back and forth email communication, ablation therapy was arranged for December 12, 2016. Somehow with luck and quick action, my wife and I were on an airplane to France and arrived in Bordeaux on December 10.

Second Ablation in Bordeaux and Use of CardioInsight Vest

The surgery on December 12 was done by Prof. Mélèze Hocini. Instead of taking the standard time of 2.5 to 3 hours for the surgery, it took well over 6 hours until approximately 4 pm. Dr Hocini was on her feet and exhausted.

My surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter.

I was informed the next day that my surgery was much more complicated than envisioned, and there were many areas that had to be ablated not only for the atrial fibrillation but also for atrial flutter. It appeared the “top” specialist I had used in Vancouver had not done his job properly. (Remember that I had been worse for the year after my first ablation).

Dr. Hocini was able to see the numerous sites leading to the atrial fibrillation/flutter in my heart due to an advanced computer assisted mapping vest (CardioInsight) which helps the electrophysiologist see in more detail cells in the heart that are acting erratically.  This system is just starting to be used in the U.S. by a few doctors. (See Bordeaux ECGI CardioInsight)

Successful Ablation—No A-Fib, But Chest Pain Condition Continues

I felt great the day after the surgery, no atrial fibrillation or flutter. Pain syndrome still there. I remained in the hospital for 4 more days and all went well, and then stayed in France for 7 more days sightseeing. No problems. I was to continue on Xarelto to keep the blood thin [for risk of stroke].

At Home A-Fib Returns with Persistent A-Flutter

Upon arriving back in Canada, the atrial fibrillation and flutter returned. Dr Hocini recommended cardioversion which I did twice but I still ended up in persistent atrial flutter with a heartbeat in the 130 range but no longer irregular.

Another cardioversion with sotalol converted my heart beat to sinus rhythm. I have now remained in rhythm since February 17, 2017.

Beta Blockers were tried to lower the heartbeat for a few weeks which did not work. Dr. Hocini recommended another cardioversion with sotalol prescribed for after the cardioversion. This was done on February 17, 2017. The heartbeat converted to sinus rhythm (65 heartbeat and was regular).

Normal Sinus Rhythm―4+ Months So Far

I have now remained in rhythm since February 17, 2017 with a quick flutter occurring once in a while. Since I am sensitive to prescription medications, I was placed on a low dose of 40 mg sotalol 2 times per day.

Minerals, Vitamin IVs for Inflammation of the Heart

With my other medical practitioners, I also had mineral and vitamin IVs during this time to help alleviate the inflammation in my heart from the surgery. I also took (and continue to take) vitamins and supplements as recommended by the other medical professionals treating me to keep the inflammation in the heart down.

Dr. Hocini had stated that since my ablation surgery was so complicated, I might have to go back to Bordeaux for another ablation. I have to get through the recommended 6 month recuperation time frame to see if the surgery has been successful. The last 3 months have me heading in the right direction of recovery.

Lessons Learned: After 23 Years with A-Fib

From this experience I’ve learned to obtain as much knowledge as possible of your condition. Trust your gut feelings if you feel uncomfortable with your surgeon. Increase your intake of nutritious foods and supplements prior to and after the surgery. Steve Ryan’s website provided me with the knowledge to make educated decisions.

If you have the funds and/or a complicated atrial fibrillation situation, please find the best surgeon you can and then still question him/her. Get a second [or third] opinion if your gut tells you to.

Doctors are just human beings with positive and negative traits like the rest of us. My first surgeon did not do his job properly in my first ablation and was flippant in his attitude in recommending a second surgical treatment.

With luck, trusting my gut instinct, educating myself, and a great family support system, I was able to find the best clinic in the world to treat me for this very debilitating medical condition.

I welcome your email if I can be of help to you.

Charn Deol, May 2017

P.S. FYI: My chest pain problem persists and goes undiagnosed, but that’s a story for another website!

Editor’s Comments:
Three month ‘blanking’ period: Charn’s A-Fib returned after his successful second ablation. This is quite common in more difficult cases. Your heart is ‘learning’ to beat normally again. That’s why doctors wait for at least three months before declaring your ablation a success. In Charn’s case, during the first two months, a couple rounds of cardioversions were followed by a third with sotalol prescribed after the cardioversion. This worked to get his heart back into and stay in normal sinus rhythm (NSR).
Be a proactive patient: Charn’s story is truly inspiring and an example of being proactive and not giving up. Do research yourself, get advice, and check out alternatives! We’ve been conditioned to trust doctors. Sometimes we just have to say “NO! That doesn’t make sense to me”. It’s okay to fire your doctor!
I told Charn an AV Node ablation is a treatment of last resort; it destroys the AV Node, the heart’s natural pacemaker. There’s no going back and you are forever pacemaker dependent.
Instead, I advised Charn to seek a second ablation and supplied him a list of Master EPs who routinely treat difficult, complex cases. Kudos to him for deciding to go to the Bordeaux group, considered the best in the world. [For more about Bordeaux, see my article, ‘2016 Cost of Ablation by Bordeaux Group (It’s Less Than You Might Think)’].
Chelation therapy: Chelation is FDA approved for lead removal and is the preferred medical treatment for metal poisoning. But few doctors perform chelation therapy or provide heavy metal testing. To find a doctor for these therapies, go to: (They also do IV therapy for vitamin C and other vitamins and minerals which seems to have helped Charn.)
Amiodarone drug therapy: Amiodarone is considered the most effective of the antiarrhythmic drugs, but it’s also the most toxic and is notorious for bad side effects, including death. It’s generally prescribed only for short periods of time such as for a few months after a catheter ablation and under very close supervision. (For more about Amiodarone, see my article, ‘Amiodarone: Most Effective and Most Toxic‘.

Read our 12-page free report.

Charn’s second ablation Operating Report: Charn’s ablation was more difficult than most. He had been in A-Fib off and on for 23 years. In addition to having to work around a previous failed ablation, Dr. Hocini had to track down and ablate many non-PV triggers. Using the CardioInsight system, Dr. Hocini found A-Fib sources in the septum and in the anterior Left Atrium (LA) region, and his left and right inferior PVs had to be re-isolated.
But Dr. Hocini didn’t stop there. Using pacing again, Dr. Hocini found peri-mitral flutter in Charn’s left atrium which terminated by completing an anterior mitral line and required high energy because of the thickness of his heart tissue. Dr. Hocini had to work on Charn for six hours to the point of exhaustion.
Charn’s chest pain continues: Charn’s debilitating chest pain seemed to start when he first developed A-Fib. I’m disappointed that being A-Fib-free didn’t get rid of the pain he still experiences. I’ve never heard of pain like this coming from A-Fib. Charn has seen many doctors and tried alternative strategies to no avail.
If anyone has any ideas, strategies, or insights to help Charn’s pain, please email me.

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If you find any errors on this page, email us. Y Last updated: Sunday, June 4, 2017



FAQ: After Ablation—What’s my Chance of Staying A-Fib Free?

There is a tendency for ablated heart tissue to heal itself, regrow the ablated tissue, reconnect, and start producing A-Fib signals again. But if this happens, it usually occurs within the first three to six months of the initial PVA(I).

An reader sent me this question about recurrence of his A-Fib after a successful ablation:

Illustration of catheter ablation

Illustration of catheter ablation of pulmonary vein

“Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

Regrowth/Reconnection of Ablated Heart Tissue

I think your chances of staying A-Fib free are pretty good.

If your Pulmonary Veins (PV) are well isolated and stay that way, you can’t get A-Fib there again. When the PVs are isolated and disconnected and haven’t reconnected, it seems to be permanent. But it’s too early in the history of PVA(I)s to say this definitively. …read the rest of my answer.

In Persistent A-Fib? Time Matters: Ablate Sooner for Better Outcomes

Note: This research study is important if you have Persistent A-Fib or your Paroxysmal A-Fib has progressed to Persistent A-Fib.

The Cost of Waiting to Ablate

In patients with persistent atrial fibrillation undergoing ablation, the time interval between the first diagnosis of persistent A-Fib and the catheter ablation procedure had a strong association with the ablation outcomes.

Cleveland Clinic researchers found that shorter diagnosis-to-ablation time spans were associated with better outcomes. Longer diagnosis-to-ablation times was associated with a greater degree of atrial remodeling.

When A-Fib becomes persistent A-Fib, the ‘first diagnosis-to-ablation time span’ had a stronger impact on outcomes than the time spent in paroxysmal A-Fib.

According to electrophysiologist Dr. Oussama Wazni, “once the diagnosis of atrial fibrillation is made, it’s important not to spend too much time trying to keep a patient in normal rhythm with medical [drug] therapy” before referring for radio-frequency ablation.” Dr. Wazni is Co-Director of the Center for Atrial Fibrillation at the Cleveland Clinic.

His comments are based on the published analysis of two-year outcomes among 1,241 consecutive patients undergoing first-time ablation of persistent atrial fibrillation over an eight-year period at Cleveland Clinic. All patients had successful isolation of all 4 PVs (pulmonary veins), and the superior vena cava was isolated in 69.6%. In addition, Left Atrium ablations (including complex fractionated electrograms) were performed in 65.6% of patients.

First Diagnosis-to-Ablation Time Span: The Shorter the Better

Importantly, the first diagnosis-to-ablation time interval (of persistent A-Fib) had a stronger impact on outcomes than the time spent with a paroxysmal A-Fib diagnosis or the duration of continuous A-Fib before the ablation procedure.

These findings suggest that A-Fib is a disease with a continuous spectrum…
The findings suggest that A-Fib is a disease with a continuous spectrum, with patients at the extreme end of that spectrum having higher arrhythmia recurrence rates after catheter ablation, whereas patients with shorter diagnosis-to-ablation times having lower recurrence rates.

The analysis was published in the Jan. 2016 issue of Circulation: Arrhythmia and Electrophysiology. (Read online or download as a PDF.)

Reference for this Article

2017 AF Symposium: Live Case of Ablation with FIRM Mapping System

Dr David Wilber Loyola University

D. Wilber, MD

In a live case, Dr. David Wilber from Loyola Un. Medical Center in Chicago, IL showed how he uses the Topera FIRM rotor mapping system to identify rotors in conjunction with a PVI. ‘FIRM’ stands for Focal Impulse and Rotor Modulation.

Patient background: The patient was a 54-year-old male in persistent A-Fib for 7 months, obese with a BMI of 31, hypertension, diabetes, and obstructive sleep apnea. He was symptomatic, with fatigue and decreased exercise tolerance. An MRI showed his Left Atrium was 15.5% fibrotic. (If using Dr. Nassir Marrouche’s Utah I–IV Classification System to rate the patient’s amount of fibrosis, this patient would be “Utah Stage 2”, i.e., a reasonable candidate for a catheter ablation.)

Voltage & FIRM Mapping: Rotors Ablated First

FIRM mapping display of left atrial rotor during atrial fibrillation.

FIRM mapping display of left atrial rotor during atrial fibrillation.

In live video streaming from Chicago, Dr. Wilber described how he first does voltage mapping while the patient is in normal sinus rhythm. He started in the right atrium, then moved to the left; he used the FIRM system to map where rotors were coming from. (In patients with persistent A-Fib, he typically finds as many as 4-8 rotors.) He mapped and ablated until there were no more rotors.

Only after using the FIRM system did he do a Pulmonary Vein ablation (PVI).

He explained that the concept of terminating A-Fib during a PVI ablation doesn’t work with the FIRM system. Instead, he looks to ablate rotational areas (which are usually 2.2 cm across). He does this by using a Contact Force sensing catheter usually at 35 watts for 30 sec.

During this ablation, he found one rotor at the base of the Left Atrial Appendage (LAA). (In the followup panel discussion, Dr. Andrea Natale commented that he and his colleagues now look first for A-Fib signals in the LAA.)

FIRM Rotors Hard to See

VIDEO examples: Dr. Wilber showed a video using FIRM in which [even to my untrained eye] it was easy to see a rotor. But he showed other videos where the overlapping, swirling waves made it difficult to see where exactly a rotor was coming from.

Editor’s Comments:
This patient was at great risk of recurrence after a catheter ablation, because of his various illnesses (comorbidities). By restoring him to normal sinus rhythm, he would be able to exercise and develop life-changing habits to reduce his obesity, diabetes, and hypertension.
ECGI CardioInsight system: Focal and re-entrant driver maps

ECGI CardioInsight system: Focal and re-entrant driver maps

Abbott Topera FIRM vs Medtronic ECGI CardioInsight:  In comparison to the ECGI CardioInsight system where the rotors and focal sources are very obvious (even to untrained observers), the FIRM system display of rotors are often confusing and hard to identify. Dr. Wilber acknowledged that it takes study and experience with the FIRM system to use it effectively.
To me, the Abbott Topera FIRM system seems hard to use. In head-to-head competition with the Medtronic ECGI CardioInsight system, I predict the FIRM system will probably not survive.
The Medtronic ECGI CardioInsight system has been in limited use in Europe and in 2017 has begun a limited rollout in the U.S.

For more on the Medtronic ECGI CardioInsight, see my article: ECGI Mapping Now Available in U.S.

For more about Dr. Nassir Marrouche’s Utah I–IV Classification System, see my article: Fibrosis Risk and the U. of Utah/CARMA website.

Reference for this Article

2017 AF Symposium: Movin’ it—Protecting the Esophagus During Ablation

2017 AF Symposium

Movin’ it: Protecting the Esophagus During Ablation

Live case presenters: Drs. Rodney Horton, Amin Al-Ahmad and David Burkhardt from the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin, TX. Moderator: Dr. Andrea Natale.

Patient background: A 79-year-old female needed a ‘re-do’ second ablation. She had persistent A-Fib and hypertension. Her first ablation was August 15, 2016 where they couldn’t terminate her Flutter. Because the temperature probe in her esophagus showed a rise in temperature when they tried to ablate certain areas, “we were not as aggressive as we would have liked.”

The Danger: Esophageal Fistula

During an ablation, doctors take great precautions to not heat or injure the esophagus which lies behind the posterior wall of the left atrium. Injuring the esophagus can, in very rare cases, cause an atrial esophageal fistula which can be fatal.

Fear of causing esophageal injury can cause the EP to modify the ablation lesion set delivery, thereby reducing ablation success by:

1. Reducing the wattage or amount of energy delivered to the left atrium wall which causes less complete scarring; and/or

2. Relocating the ablation lesion to a less desirable area

For this patient: During her first ablation: the doctors noticed a rise in temperature of the probe inserted in her esophagus, so her doctors stopped ablating in that area. Consequently, the A-Fib signal source(s) in that area were not isolated effectively. Result: her A-Flutter was not terminated.

Solution: Esophageal Displacement Tool

The esophagus is not a rigid, inflexible pipe but rather like a hose made out of flexible muscle fibers. It can naturally migrate side-to-side 2-3 cm on its own.

For this live streaming ablation, a new esophagus displacement tool was used: the EsoSure Esophageal Retractor. The tool allows doctors to re-position a section of the esophagus away from the nearby heart tissue and avoid the heat generated during ablation.

The inventor of the device, Steven W. Miller, RN and EP nurse, demonstrated his device to me at the AF Symposium Exhibit Hall.

EsoSure Esophageal Retractor: Shape adjusts to body temperature at

EsoSure Esophageal Retractor: Shape adjusts to body temperature

At room temperature, the stylet is fairly straight which allows it to be easily inserted into a commonly used gastric tube which is routinely placed down the esophagus by the anesthesia staff. But as the stylet warms to body temperature, it takes on a greater curve. He inserted the stylet into warmed water. You could see how the stylet changed shape and developed a greater curve.

Depending on how the stylet is positioned, it can displace the esophagus up to 2-3 cm to the left or right depending on each person’s anatomy.

Using the EsoSure Retractor, the EP can easily and safely move the esophagus away from any area being ablated. It is FDA approved and has been used by different practitioners more than 700 times without damaging the esophagus.

Live Case Using the EsoSure Retractor

In this re-do ablation, the 79-year-old female patient was in A-Fib when the ablation started. They cardioverted her, but she went right back into A-Fib.

Entrainment (pacing) mapping was used to identify non-PV triggers. Since they had to ablate in the posterior of the left atrium next to the esophagus, they simply moved the EsoSure Retractor up and down to displace the esophagus. It seemed very easy to do.

The EPs mentioned that, with the use of this displacement device, they could now ablate at a higher wattage without fear of harming the esophagus. They also ablated the Left Atrial Appendage area to restore her to sinus rhythm.

What Patients Need to Know

Displacing the esophagus is a major medical advance: The EsoSure Esophageal Retractor is a major medical advance that will significantly improve not only the safety but the effectiveness of catheter ablations. Compared to any other gear in the ablation lab, the EsoSure Retractor is inexpensive ($365-$395 depending on quantity ordered). Any EP lab can and should use it, (or something similar).

Esophagus injury: All too often the esophagus lies behind the right pulmonary vein openings. Doctors have to limit both the placement and the power of their lesions out of fear of damaging the esophagus.

But being able to move the esophagus solves this problem. Ablations will be more effective, and the danger of producing an Atrial Esophageal Fistula (while rare) will be greatly reduced, if not eliminated. It will also reduce ablation procedure time.

Ask your EP: If you are scheduling an ablation, ask your doctors about their plan to prevent esophageal injury.

Return to 2017 AF Symposium Reports
If you find any errors on this page, email us. Last updated: Saturday, March 11, 2017

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